Download MANDIBULAR SPACE INFEctions A. Submental Bounded by the

BATCH 2011
ORAL PATHOLOGY
Spread of Infection Part II
Dr. Michelle Marie Meneses
Angel and Madel
07 09 09
MANDIBULAR SPACE INFECTIONS
A. Submental
 Bounded by the anterior belly of digastric


(bounds incisors), mylohyoid muscles (muscle
that covers floor of the mouth)
From infection of lower incisors  vestibule 
chin or to submental space
Isolated submental infection is rare
FIG. 16-9 Submandibular space lies between mylohyoid muscle and
skin and superficial fascia. Primarily second and third molars infect it
B. Sublingual (SL) /Submandibular (SMd)
Ludwig’s Angina
 Usually involves:




Mylohyoid
Line: creates a
plane that
divides
submandibular
and sublingual
space


 When all the
mandibular spaces are
involved
bilaterally
(submental, sublingual and
submandibular are all
involved)
 Acute,
rapid,
diffused
septic
inflammatory
indurated
bilateral cellulitis on the
floor of the mouth and
neck
 Elevated tongue,
high fever, rapid pulse,
fast perspiration (difficulty
 Sublingual: (underneath tongue) PM – 1st M
 Submandibular: (parotid/lymph node area)
2nd & 3rd M
Location of infection is dependent on mylohyoid
muscle
Tongue elevation (SL) (paangat ung expansion,
tongue is pushed back, dyspnea occurs)
Communicates with other spaces
Lymph nodes enlarge at the angle of the
mandible
Infection ABOVE the mylohyoid line- spread to
SUBLINGUAL SPACE
Infection BELOW the mylohyoid line- spread to
SUBMANDIBULAR SPACE
in breathing due to swelling)
Characterized by extreme hardness of the floor of the
mouth, "brawny", "indurated" swelling (no give or
fluctuation due to pus formation) of the neck centering
about the floor of the mouth and by the ensuing elevation
of the mucosa of the mouth and tongue. Interstitial spaces
are filled with fluid
 The infection here may eventually extend to the
lateral pharyngeal space and then may enter the
retropharyngeal space and even descend to the
mediastinum
 Death from Ludwig's angina occurs as a result of
suffocation due to edema of the mouth, tongue, and
the glottis, from mediastinitis due to spread, or from
septicemia or pneumonia
 May lead to septic shock then death
 Incision & Drainage (I & D) with antibiotic therapy


Submaxillary = submandibular daw
(Penicillin/Streptomycin/Tetracycline) 
intramuscular (IM) for faster spread
Fasciae are connected, so when there is
expansion in one space, infection is spread easily
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SECONDARY SPACE INFECTIONS




Severe cases, greater complications
Poor blood supply, difficult to treat
Occur when primary space infections are not treated
Masticatory Space: masseteric, pterygomandibular
and temporal spaces
CERVICAL SPACE INFECTIONS
 From PMS
 Medial to the internal pterygoid, lateral to superior
pharyngeal constrictor
 Styloid process divides it:
A. Masseteric




Between masseter and ramus of the mandible
Spread from buccal space
Trismus (diificulty in opening the mouth)
Angle of the jaw is swollen
B. Pterygomandibular Space (PMS)
 Between internal pterygoid muscle and ramus of



the mandible
Spread from Submandibular/Sublingual or due to
pericoronitis or infected needle
 Pericoronitis (loose tissue covering
partially erupted teeth, food enters and not
brushed, inflammation develops)
If PMS involvement only, no external swelling but
trismus
Inferior to infratemporal space, behind 3rd molar



 Anterior: muscles- internal pterygoid muscle
 Posterior: carotid sheath (internal jugular vein,
internal carotid artery), cranial nerves (IX, X, XI), and
cervical symphatetic trunk
Lateral swelling of neck, trismus
Lateral pharyngeal wall swelling  dysphagia
Involvement of the contents is dangerous
A. Lateral Pharyngeal
 Cervical area of submandibular
 Thin fascia covering: blood vessels can perforate,
infection can spread easily
C. Temporal
 Superficial Temporal
 Extends to temporal fascia
 Deep Temporal
 Continuous with infratemporal space (ITS)
 Only in severe infections, rare
 Swelling in the temporal area is up to
zygoma posterior to orbital rim
FIG. 16-11 Lateral pharyngeal space is located between medial
pterygoid muscle on lateral aspect and superior pharyngeal
constrictor on medial aspect. Retropharyngeal and prevertebral
spaces lie between pharynx and vertebral column. Retropharyngeal
space lies between superi-or constrictor muscle and alar portion of
prevertebral fascia. Prevertebral spaces lie between alar layer and
prevertebral fascia.
B. Retropharyngeal
 Between




prevertebral space and superior
constrictor muscle
From base of the skull to C7 or T1
No contents but close to mediastinum (close to
lungs and heart)
Danger to the airway
Signs and symptoms:
 Fever
 Pain and neck rigidity
 Dysphagia
 Dyspnea
 Laryngeal edema
 Airway obstruction
C. Prevertebral
 Base of the skull to the diaphragm (proximity to
thorax/mediastinum)
 Danger:
 airway obstruction
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 perforation (aspiration) – septic (pus in the
lungs)
 spread to mediastinum
5. Reevaluation

Recall and check for recurrence of infection
SUMMARY
FIG. 16-12 If retropharyngeal space is involved, posterosuperior
mediastinum may also become infected secondarily. If prevertebral
space is infected, inferior boundary is diaphragm, so entire mediastinum is at risk. Alar fascia divides prevertebral and
retropharyngeal spaces
TREATMENT
1. Medical support (host defense/airway)
 Make patient comfortable- analgesia, maintain patent
airway, boost host’s immune system, intravenous tx
2. Antibiotics

Aerobic/anaerobic,
infection)
broad
spectrum
(determine
3. Surgical removal of source

Extract tooth or RCT
4. Drainage

I & D aids faster  no waiting time for healing and
profound effect of antibiotic
FIG.
16-14
Typical
incision and drainage
(I&D) sites for various
fascial space infections.
Superficial and deep
temporal space (A).
Submandibular
masseteric
and
pterygomandibular
spaces (B). Sub-mental
space
(C).
Lateral
pharyngeal
and
retropharyngeal spaces
(D).
Hello ulit sa ting lahat…Mwaahhh….
NASIRA UNG NIRECORD KO. Huhuhu. Kaya kumuha
nalang ako sa net ng idinagdag. Ung mga pic di maam di ko kasi mahagilap
kaya kung ano nalang ung nakita ko, un nalang. Hehe. Hello sa mga GHC4
papas. Bwahahahaha. Kay mickomander, kay red hot chili pepper, sa naliligo
sa batis na si kristo at sa kamukha ng crush ni bom. Hahahahahaha. Aun
lang. Ingat po sa pag edit, madali po magulo ung mga pics ^_^ Angel
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